Provider Demographics
NPI:1619992732
Name:MUTH, DEBRA A (NP)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:A
Last Name:MUTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2607 N GRANDVIEW BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1686
Mailing Address - Country:US
Mailing Address - Phone:262-522-8640
Mailing Address - Fax:262-522-8649
Practice Address - Street 1:2607 N GRANDVIEW BLVD STE 150
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1686
Practice Address - Country:US
Practice Address - Phone:262-522-8640
Practice Address - Fax:262-522-8649
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2012-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1167-033363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIS92024Medicare UPIN